Commentary: Disease etiology and political ideology: revisiting Erwin H Ackerknecht's Classic 1948 Essay, ‘Anticontagionism between 1821 and 1867’
Center for the History of Medicine, University of Michigan, MI, USA.
* Corresponding author. Center for the History of Medicine, University of Michigan, MI, USA. E-mail: amstern@umich.edu
Accepted 3 June 2008
Virtually every academic society sponsors an annual address given by one of its leading lights, and the American Association of the History of Medicine is no exception. The Garrison Lecture, named for the eminent historian Fielding H Garrison, was established in 1940 and continues to be a major event for historians of medicine to this day. Yet relatively few are read and cited as much as the seminal lecture ‘Anticontagionism between 1821 and 1867,’ delivered by Erwin Ackerknecht in 1947 and published the following year (as is every Garrison lecture) in the Bulletin of the History of Medicine. For 60 years, this essay has shown remarkable intellectual staying power and continues to engage and provoke historians, above all those who study epidemics, public health and theories of disease causation and transmission across time. Moreover, even as scholars have mobilized fresh evidence that challenges and complicates Ackerknecht's thesis, the analytical approach of ‘Anticontagionism between 1821 and 1867’ remains relevant and intellectually valuable in the 21st century.
Acknerknecht delivered this lecture one year after accepting a newly-created chair in the history of medicine at the University of Wisconsin, one of the oldest established positions in the United States (the first was the Welch Professorship at Johns Hopkins Institute of Medicine in 1934).1 After a tumultuous decade of short-term posts at universities and museums that followed his escape from Nazi Germany in 1941, Ackerknecht relished the opportunity he found in Madison to immerse himself in research and writing. A refugee scarred by totalitarianism yet cynical toward leftist political organizations, Ackerknecht explored critical questions about the role of medicine and health in Europe during the emergence and consolidation of the modern nation-state. Reflecting his own traveled path and anticipating the recent turn towards global health, Ackerknecht consistently applied a transnational and comparative lens to the past. Indeed, ‘Anticontagionism between 1821 and 1867’ deserves a privileged place in the history of international health and epidemiology, as it poignantly reminds us that epidemics must be understood in their broader political, social, cultural, economic and geographic contexts.
In ‘Anticontagionism between 1821 and 1867’ Ackerknecht pursued two principal lines of inquiry. First, he wanted to explain why anticontagionism and its attendant theories of disease transmission—based on shifting concepts of miasma, atmosphere and localism—crested not in the days immediately before the ground-breaking discoveries of Louis Pasteur and Robert Koch in the 1870s and 1880s, but almost half a century earlier. In other words, why had most physicians abandoned anticontagionism for contagionism by the 1850s, decades before the germ theory of disease and bacteriology crystallized as core tenets of modern public health and epidemiology? Second, Ackerknecht was eager to determine why, given shared medical knowledge, nation–states chose different strategies in their attempts to control and mitigate diseases. For example, while from 1800 to 1850 some countries, such as Germany and Austria, favoured quarantines and the strict regulation of the movement of people and things, others, such as Britain, avoided such heavy-handed interventions and instead focused primarily on environmental amelioration and sanitary campaigns.
Ackerknecht answered both these questions with a structuralist analysis of political ideology, concluding that a physician's beliefs about disease etiology were based first and foremost on his socio-economic position and stance towards state regulation. According to Ackerknecht, in the mid-19th century scientific knowledge about disease etiology was equivocal enough to allow physicians to select viable explanations for epidemic outbreaks from contagionism or anticontagionism. Given the plausibility of either explanation, a physician's ideological bent only could be explained by class position, and to a lesser degree, personal idiosyncrasies. As Ackerknecht wrote, ‘this accident of personal experience and temperament, and especially economic outlook at political loyalties will determine the decision. These, being liberal and bourgeois in the majority of the physicians of the time brought about the victory of anticontagionism. It is typical that the ascendancy of anticontagionism coincides with the rise of liberalism, its decline with the victory of the reaction.’2 Yet one of the great strengths of Ackerknecht's essay was that he did not reduce this history to a cast of historical characters, but instead keenly situated conflicting theories of disease etiology in the maelstrom of political crises and revolutions that gripped 19th century Europe. In this setting, anticontagionists were usually radicals and liberals suspicious of the state and disdainful of quarantines as despotic interventions. Emblematic of this viewpoint was the Marxist Rudolf Virchow, a brilliant Polish scientist whose famous ‘Report on the Typhus Epidemic in Upper Silesia’ (1848) blamed squalid local conditions and the viciousness of Prussian authoritarianism for the epidemic, and recommended revolutionary economic, social and political change as remedy.3 On the other side of the spectrum were the militarists and bureaucrats, who supported contagionism and the use of state powers and laws in the name of disease regulation. Over time, however, anticontagionsm, like radicalism and anarchism, buckled under the mounting weight of state power and bureaucracies and was supplanted by the contagionist consensus. The growing currency of contagionism was evident in 1851, when 11 European countries organized the first of many international sanitary conferences, with the goal of developing shared regulations for the containment, usually through quarantine and isolation, of infectious diseases including cholera, yellow fever and typhus.4
To Ackerknecht's credit, he also recognized that many physicians did not fall neatly into the contagionist or anticontagionist camp. As his essay carefully delineates, most scientists at the time believed that some ailments, such as syphilis and smallpox, were contagious. The question mark of etiology hung most heavily over the classic scourges—yellow fever, cholera, plague and typhus—that erupted in communities, incited panic and left scores dead or debilitated. Examining these four diseases in detail, Ackerknecht demonstrated it was yellow fever, which many French and British physicians encountered and studied during scientific colonial missions, that first and foremost bolstered anticontagionist thinking and ‘set a fatal pattern for later discussions on cholera and plague’.5 In keeping with this trend, when cholera appeared around the world in 1832–33 and 1849–50, anticontagionist explanations won the day. In practice this meant that rather than quarantines, physicians implemented extensive sanitary efforts to clean up decay, filth, and dirty water—the noxious environmental factors that many believed permitted disease to generate and spread. In Europe, this pattern occurred most notably in Britain and Holland, and was emulated across the Atlantic in response to the wrath of cholera as well as other endemic and epidemic diseases.6–9
Since it was published in 1948, Ackerknecht's rise-and-fall narrative of anticontagionism has served as a critical foundation for the modern history of public health and epidemics.10 Nevertheless, some historians have taken issue with Ackerknecht's thesis, criticizing its simplicity and superficiality, and what Peter Baldwin has termed an assumed ‘correspondence between politics and prophylaxis’.11 In his book on the state and public health in 19th century Europe, Baldwin argues that Ackerknecht grossly underestimated the complexity of national responses to epidemics based on ‘geographic, economic, administrative and political factors’ and provides rich accounts of these in Sweden, Germany, Britain and France.12 In a similar vein, other historians have taken Ackerknecht to task for such oversights as not adequately exploring the function of air in theories of disease transmission, conflating contagionism with quarantine and underplaying the role of contingent contagionism.13
It is true that Ackerknecht's argument falters when subjected to fine-grained analysis of the development of public health agencies and medical societies and the suasion of individual physicians trained in distinct national milieus. Yet the very fact that Ackerknecht's thesis has prompted extensive and illuminating counter-research demonstrates the extent to which his framework has continued to guide contemporary scholarship on 19th century epidemics and public health. In addition, although scholars might argue that Ackerknecht is too pat in his associations—of quarantine with contagionism and sanitarianism with anticontagionism—in recent years many historians have deserted his incisive interest in political economy and ideology. That these kinds of questions appeal more to sociologists and social epidemiologists than medical historians is more than a quaint intellectual shame, as it has ramifications for the potential impact of history on health policy. For example, historians would benefit from following the Ackerknechtian impulse today, by exploring how approaches to vaccines—including funding, manufacturing, distribution, and access—have varied from country to country over time, and what this reveals about political ideology and social priorities. With respect to theories of disease etiology, Ackerknecht's insights about liberal vs authoritarian stances on health interventions remain instructive when we reflect on the initial years of the AIDS epidemic when communities responded with a haphazard mixture of confusion, discrimination and compassion.
In sum, Ackerknecht's essay remains a cornerstone publication in the history of epidemics and public health, and a valuable starting point for examining the intersections of disease etiology and political ideology from national and international perspectives. Like many lasting and valuable pieces of scholarship, ‘Anticontagionism between 1821 and 1867’ offers a mobile prism that can be applied to various historical contexts and problems. Ultimately, Ackerknecht did not provide the definitive explanation for anticontagionism's early 19th century popularity, but he probably would have regarded such a quest with skepticism. Indeed, Ackerknecht concluded his Garrison lecture by reminding his audience of the dangers of the kind of intellectual hubris exhibited by the diehard anticontagionists of the mid-19th Europe, and exhorted his generation not to fall into the trap of assuming their ideas were defined by ‘an intellectual or moral superiority of ours’.14
Conflict of interest: None declared.
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